			<table width="500" height="230" border="1" align="center" cellpadding="1" cellspacing="1" style="background-color: white; font-family: sans-serif;">
				<tr>
					<td align='center' style="font-size: 20px; color: red; "> หากไม่สามารถปริ้นใบ Payment ได้ กรุณาติดต่อ HBC</td>
				</tr>
				<tr>
					<td align="center" valign="top">
						<table width="500" border="0" align="center" cellpadding="4" cellspacing="0" style="margin: 5px 5px 5px 5px; background-color: #adeae9; font-size: 22px;">
							<tr>
								<td colspan="2" align="center" valign="middle"><font size="5"><b>ยืนยันการทำ Payment </b></font></td>
							</tr>
							<!--<tr height="20">
								<td width="250" bgcolor="#adeae9" align="right">Payment ID : </td>
								<td width="450" bgcolor="#adeae9" align="left"><span style="color: red;">{$data.payment_id}</span></td>
							</tr>-->
							<tr height="20">
								<td width="250" bgcolor="#adeae9" align="right">Charge : </td>
								<td width="250" bgcolor="#adeae9" align="left"><span style="color: red;">{$data.charge}&nbsp;&nbsp;บาท</span></td>
							</tr>
							<tr height="20">
								<td bgcolor="#adeae9" align="right">Discount. : </td>
								<td bgcolor="#adeae9" align="left">{$data.discount}&nbsp;&nbsp;บาท</td>
							</tr>
							<tr height="20">
								<td bgcolor="#adeae9" align="right"><font color="red">Pre Approved : </font></td>
								<td bgcolor="#adeae9" align="left">{$data.pre_approved}&nbsp;&nbsp;บาท</td>
							</tr>
							<tr height="20">
								<td bgcolor="#adeae9" align="right"><font color="red">Non Covered : </font></td>
								<td bgcolor="#adeae9" align="left">{$data.non_covered}&nbsp;&nbsp;บาท</td>
							</tr>
							<tr>
								<td colspan="2" align="center" valign="middle">
									<input type="hidden" name="hid_payment_id" id="hid_payment_id" value="{$data.payment_id}">
									<input type="hidden" name="hid_user_id" id="hid_user_id" value="{$data.userid}">
									<input type="hidden" name="hid_preauth_id" id="hid_preauth_id" value="{$data.preauth_id}">
									<input type="hidden" name="hid_policy_no" id="hid_policy_no" value="{$data.policy_no}">
									<input type="hidden" name="hid_payment_datetime" id="hid_payment_datetime" value="{$data.payment_datetime}">
									<input type="hidden" name="hid_payment_status" id="hid_payment_status" value="{$data.payment_status}">
									<input type="hidden" name="hid_customer_type" id="hid_customer_type" value="{$data.customer_type}">
									<input type="hidden" name="hid_policy_id" id="hid_policy_id" value="{$data.policy_id}">
									<input type="hidden" name="hid_payment_type" id="hid_payment_type" value="{$data.payment_type}">
									<input type="hidden" name="hid_acc_date" id="hid_acc_date" value="{$data.acc_date}">
									<input type="hidden" name="hid_admis_date" id="hid_admis_date" value="{$data.admis_date}">
									<input type="hidden" name="hid_deductible" id="hid_deductible" value="{$data.deductible}">
									<input type="hidden" name="hid_charge" id="hid_charge" value="{$data.charge}">
									<input type="hidden" name="hid_discount" id="hid_discount" value="{$data.discount}">
									<input type="hidden" name="hid_co_payment" id="hid_co_payment" value="{$data.co_payment}">
									<input type="hidden" name="hid_pre_approved" id="hid_pre_approved" value="{$data.pre_approved}">
									<input type="hidden" name="hid_non_covered" id="hid_non_covered" value="{$data.non_covered}">
									<input type="hidden" name="hid_indiation_admit" id="hid_indiation_admit" value="{$data.indiation_admit}">
									<input type="hidden" name="hid_last_acc" id="hid_last_acc" value="{$data.last_acc}">
									<input type="submit" name="btn_confirm" id="btn_confirm" value="ยืนยัน" style="width:150px; height:40px;" onclick="_renderInsertPayment();">
									<a id="link_preauth_fund"></a>
									&nbsp;&nbsp;
									<input type="button" name="btn_cancel" id="btn_cancel" value="ยกเลิก" style="width:150px; height:40px;" onClick="closeLightBox('link_preauth_fund','fancybox-ajax-light');">								
								</td>
							</tr>
						</table>
					</td>
				</tr>
			</table>